Reversible hepatofugal portal flow after liver transplantation using a small-for-size graft from a living donor

We describe a case of reversible hepatofugal portal flow 1 week after transplantation of a small-for-size liver graft from a living donor. A transient increase in intrahepatic portal vascular resistance was the suspected cause. The portal venous flow normalized after residual collateral channels had been interrupted surgically. The patient was discharged on the 90^th postoperative day. Liver transplant clinicians should be aware that hepatofugal flow can occur with small-for-size liver grafts, despite sufficient portal venous flow immediately after transplantation. Received: 8 March 2000 Revised: 26 September 2000 Accepted: 5 May 2001     

End-to-side portocaval shunting for a small-for-size graft in living donor liver transplantation.

In the development of adult-to-adult living donor liver transplantation (LDLT), the small-for-size graft has been associated with poor clinical outcome. Persistent portal hypertension or portal venous overperfusion are considered to be causative factors, and partial diversion of portal flow to systemic circulation may be effective for avoiding injuries that occur in the small-for-size (SFS) graft. Recently, we constructed an end-to-side portocaval shunting using 1 of the portal branches and anastomosed the other branch with the portal vein of the graft in 2 cases of LDLT recipients transplanted with a SFS graft. With the suppression of portal hypertension, as well as sufficient portal flow to the graft, the recipients recovered successfully with favorable graft function. This new and simple technique may be able to be used as a feasible and effective method to attenuate the SFS syndrome.     

Life-Threatening Portal Flow Steal Reappearing Under Increased Intrahepatic Vascular Resistance After Living Donor Liver Transplantation

Maintenance of adequate portal inflow is crucial for graft regeneration in adult living donor liver transplantation (ALDLT) to allow the recipients to meet their early metabolic demands. A persistent large spontaneous portosystemic shunt can divert portal flow away from the liver graft, leading to impaired or delayed graft regeneration and subsequent graft failure. The importance of obliterating huge portosystemic shunt during liver transplantation is obvious for successful ALDLT. However, in partial liver graft with a relatively small graft-to-recipient weight ratio (GRWR) (compared with deceased donor whole graft liver transplantation), even the persisting small portosystemic shunt may result in repeated portal flow steal when a liver graft faces increased intrahepatic vascular resistance caused by rejection or graft congestion with hepatic venous outflow stenosis. We present 2 complicated cases of reappearing portal flow steal that were derived from the remaining small portosystemic shunt under the increased vascular resistance of the liver graft, even after interruption of a large portosystemic shunt during ALDLT. Because ALDLT is always a partial liver graft, even when GRWR is over 1%, it is much more vulnerable to hemodynamic changes in portal flow by rejection or graft congestion by hepatic venous outflow obstruction. Therefore, a comprehensive understanding of complex portosystemic shunt and complete reinterruption of reappearing portosystemic shunt, even though small and insignificant, during ALDLT is important for graft salvage procedures before irreversible liver graft damage.     

The interrelationship between portal and arterial blood flow after adult to adult living donor liver transplantation

BACKGROUND: When adults are transplanted with segmental grafts, disparity between the size of the graft and the native organ is almost universal. These grafts presumably still receive all of the native portal inflow despite a reduced vascular bed and dramatically elevated blood flow may result. The hemodynamic changes after segmental transplantation in adults have not yet been studied and their clinical significance is unknown. METHODS: Portal venous and hepatic arterial blood flow were measured intraoperatively in right lobe liver donors and recipients with electromagnetic flow probes. Postoperative evolution was monitored in recipients with ultrasonography. RESULTS: Portal flow to the right lobe ranged from 601 to 1,102 ml/min before resection and from 1,257 to 2,362 ml/min after transplantation. There was a statistically significant linear correlation between the change in portal flow and graft to recipient body weight ratio. Arterial blood flow ranged from 213 to 460 ml/min before resection and from 60 to 300 ml/min after transplantation. Preoperative portal peak systolic velocity was uniformly around 10 cm/sec. Values on postoperative day 1 were increased to 30 cm/sec in recipients of cadaveric organs, to 50 cm/sec in recipients of organs with graft to recipient body weight ratios of more than 1.2%, and to 115 cm/sec in recipients of organs with ratios less than 0.9%. A decreasing tendency was universally observed. Arterial systolic velocity was inversely related to portal systolic velocity. Neither graft dysfunction nor vascular complications occurred. CONCLUSIONS: The hemodynamic pattern after right lobe transplantation is predictable and intraoperative measurements and ultrasonography are useful for monitoring. The size of the graft influences the magnitude of the hemodynamic changes.     

Early vascular complications after pediatric liver transplantation

Vascular complications have a detrimental effect on the outcome after liver transplantation. Most studies focus exclusively on hepatic artery thrombosis (HAT). The current study analyzed the incidence, consequences, and risk factors for HAT, portal vein thrombosis (PVT), and venous outflow tract obstruction (VOTO) in a consecutive series of 157 pediatric liver transplantations. The overall incidence of vascular complications was 21%. The incidences of HAT, PVT, and VOTO were 10%, 4%, and 6%, respectively. Patient survival after PVT and VOTO and graft survival after HAT and PVT were less compared with survival of grafts without vascular complications. To identify risk factors for vascular complications, factors related to recipient, donor, and surgical techniques were analyzed. A low donor-recipient (D/R) age ratio, long surgical time, and use of the proper hepatic artery of the recipient for arterial reconstruction were risk factors for HAT Young age, low weight, segmental grafts, and piggyback technique were risk factors for PVT. Fulminant hepatic failure, high D/R age and weight ratios, and use of segmental grafts were related to VOTO. Vascular complications, which occurred in 21% of the pediatric liver transplantations, had a significant impact on patient and graft survival. Size disparity between donor and recipient was an important risk factor for vascular complications, especially in the case of transplantation of segmental grafts. Patient and graft survival might improve by avoiding the identified risk factors.     

Isolated adult intestinal transplantation using portal venous drainage

There is some evidence that portal venous drainage may offer immunologic and metabolic advantages in small bowel transplantation. Isolated small bowel transplantation was performed in 14 adult patients. In all cases, the donor pancreas was transplanted into another patient. During the donor procedure, the superior mesenteric artery and vein were separated below the division of the inferior pancreaticoduodenal artery and below the veins of the pancreatic head. An arterial interposition graft was used in all cases. One donor mesenteric artery was reconstructed in 6 patients; two arteries in 5 patients; and three arteries in 3 patients. Proximal arteries of the graft were ligated and the upper part of the jejunum resected. In 10 patients, a direct anastomosis was performed in an end-to side fashion between donor superior mesenteric vein (SMV) and recipient inferior mesenteric vein (IMV). In 2 patients, a branch of the superior mesenteric vein was used and 2 patients required a venous interposition graft to confluence using the donor iliac vein. Patency of the venous anastomosis was documented by magnetic resonance imaging (MRI) angiography after 6 months. No vascular complications have been observed to date. Portal venous drainage is technically feasible in most cases. An anastomosis to the recipient IMV offers the advantage of being direct despite the short donor vein segment. Furthermore, donor and recipient vessels are well matched for size. Using microsurgical techniques, vascular complications may be avoided.     

Venous complications after orthotopic liver transplantation

We report venous complications, including portal vein and hepatic vein stenoses, that required interventional radiological treatment in three pediatric and two adult living related liver transplant recipients. Between April 2001 and April 2005, 81 liver transplantations were performed at our hospital. Sixty-two grafts were from living donors. During follow-up, three portal vein stenoses were identified in three pediatric recipients, and two hepatic vein stenoses in two adult patients. In the children, two had received left lateral segment grafts, and one had received a right lobe graft from two mothers and one father, respectively. The etiologies of liver failure were Alagille syndrome, biliary atresia, and fulminant Wilson's disease. Portal vein stenoses were identified at 8, 11, and 12 months after transplantation; all three patients underwent percutaneous transhepatic portal venous angioplasty with a success rate of 100%. The mean follow-up was 102 days; no recurrence has occurred. In contrast, hepatic venous stenoses were diagnosed in two adult recipients. One of them was a 24-year-old woman with autoimmune hepatitis and the other a 43-year-old man with cryptogenic cirrhosis. Hepatic vein stenoses were diagnosed at 3 and 4 months after transplantation. Both hepatic vein stenoses were dilated with balloon angioplasties via the transjugular route. Venous complications identified by Doppler ultrasonography were confirmed by computerized tomographic angiography. Angioplasty represents an effective and safe alternative to reconstructive surgery in the treatment of venous complications after liver transplantation.     

Vascular complications after living donor liver transplantation: a Brazilian, single-center experience

Background

In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center.

Methods

Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg).

Results

Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months.

Conclusion

Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).     

One hundred in situ split-liver transplantations: a single-center experience

OBJECTIVE: To identify predictors of graft and recipient survival from a single-institution series of in situ split-liver transplantations and compare outcomes to living donor and whole organs for adults and children. SUMMARY BACKGROUND DATA: Split-liver transplantation is a surgical technique that creates 2 allografts from a single cadaver donor. We have applied split-liver transplantation to all indications and categories of medical urgency for initial as well as retransplantation to expand the current donor pool and decrease reliance upon living donation. METHODS: A retrospective analysis was conducted of 100 consecutive in situ split-liver transplantations yielding a left lateral segment and right trisegment graft that were performed at the University of California Los Angeles between 9/91 and 02/03. These 100 transplantations generated 190 allografts for transplantation into 105 children and 60 adults, with the sharing of 25 allografts among transplant centers across the United States. Outcomes and incidence of complications were compared with living donor and whole organ recipients receiving liver transplantation during the same time period with independent predictors of split-liver graft and recipient survival identified by multivariate analysis. RESULTS: The incidence of biliary and vascular complications observed in recipients of left lateral segment grafts created by split-liver transplantation was not statistically different from recipients of left lateral segment grafts created from living donation or children receiving whole-organ grafts from pediatric donors. Kaplan-Meier survival estimations of left lateral segment graft and recipient survival also demonstrated no statistical difference among split-liver, living donor, and whole-organ recipients. Right trisegment grafts from split-liver transplantation demonstrated a 10% incidence of biliary and 7% incidence of vascular complications. Long-term graft function was excellent with patient and graft survival equal to 1086 recipients of cadaver whole-organ grafts from donors ages 10-40 years who underwent transplant operations during the same time period. Predictors of split-liver transplantation graft and recipient survival included United Network for Organ Sharing status at transplantation, indication, occurrence of a complication, donor creatinine, and donor length of hospitalization. CONCLUSIONS: Split-liver transplantation is an effective mechanism for immediate expansion of the cadaver donor pool that can reduce dependence upon living donation in adults and children.     

Biliary complications after adult living donor liver transplantation

We evaluated the causes and outcomes of biliary complications occurring after adult living donor liver transplantation (ALDLT) in a large patient cohort. Among 46 patients who underwent ALDLT at two different centers early bile duct complications occurred in 11 recipients (23.9%), consisting of leakage from the anastomotic site or from the cut surface of the liver. T-tube-associated biliary complications occurred in four patients. Late complications, primarily anastomotic strictures, occurred in 15 patients (32.6%) at 6.7+/-3.5 months after transplantation. Surgical intervention was generally required for early biliary complications but rarely necessary for late complications. No graft loss was caused by biliary complications. Thus, ALDLT is accompanied by a high rate of biliary complications, which in our series have been of low severity. However, long-term effects on graft function are not yet known.     

Outcome of the use of pediatric donor livers in adult recipients

The prolonged waiting time caused by the lack of donor livers leads to an increasing number of terminally ill patients waiting for lifesaving liver transplantation. To rescue these patients, transplant programs are accepting donor organs from the expanded donor pool, using donors of increasingly older age, as well as from the pediatric age group, often despite significant mismatch in liver size. We investigated the outcome of 102 consecutive liver transplantations using pediatric donor livers in adult recipients. One-year graft survival using donors aged 12 years or younger (group 1, n = 14) and donors aged 12 to 18 years (group 2, n = 88) was compared. In addition, risk factors for graft loss and vascular complications were analyzed. The 1-year graft survival rate in adult transplant recipients in group 1 was 64.3% compared with 87.5% in those in group 2 (P = .015). The main cause of graft loss was arterial complications, occurring in 5 of 16 transplant recipients (31.3%). Major risk factors for graft loss and vascular complications were related to the size of the donor: age, height and weight, body surface area of donor and recipient, and warm ischemic time. We conclude that the outcome of small pediatric donor livers in adult recipients is poor, mainly because of the increased incidence of arterial complications. When a pediatric donor is used in an adult recipient, ischemic time should be kept to a minimum and anticoagulative therapy should be administered in the immediate postoperative period to avoid arterial complications. However, because small pediatric donors are the only source of lifesaving organs for the infant recipient, the use of small pediatric donor livers in adults should be avoided. (Liver transpl 2001;7:38-40.)     

2,500 living donor kidney transplants: a single-center experience

OBJECTIVE: To review a single center's experience and outcome with living donor transplants. SUMMARY BACKGROUND DATA: Outcome after living donor transplants is better than after cadaver donor transplants. Since the inception of the authors' program, they have performed 2,540 living donor transplants. For the most recent cohort of recipients, improvements in patient care and immunosuppressive protocols have improved outcome. In this review, the authors analyzed outcome in relation to protocol. METHODS: The authors studied patient and graft survival by decade. For those transplanted in the 1990s, the impact of immunosuppressive protocol, donor source, diabetes, and preemptive transplantation was analyzed. The incidence of rejection, posttransplant steroid-related complications, and return to work was determined. Finally, multivariate analysis was used to study risk factors for worse 1-year graft survival and, for those with graft function at 1 year, to study risk factors for worse long-term survival. RESULTS: For each decade since 1960, outcome has improved after living donor transplants. Compared with patients transplanted in the 1960s, those transplanted in the 1990s have better 8-year actuarial patient and graft survival rates. Death with function and chronic rejection have continued to be a major cause of graft loss, whereas acute rejection has become a rare cause of graft loss. Cardiovascular deaths have become a more predominant cause of patient death; infection has decreased. Donor source (e.g., ideally HLA-identical sibling) continues to be important. For living donor transplants, rejection and graft survival rates are related to donor source. The authors show that patients who had preemptive transplants or less than 1 year of dialysis have better 5-year graft survival and more frequently return to full-time employment. Readmission and complications remain problems; of patients transplanted in the 1990s, only 36% never required readmission. Similarly, steroid-related complications remain common. The authors' multivariate analysis shows that the major risk factor for worse 1-year graft survival was delayed graft function. For recipients with 1-year graft survival, risk factors for worse long-term outcome were pretransplant smoking, pretransplant peripheral vascular disease, pretransplant dialysis for more than 1 year, one or more acute rejection episodes, and donor age older than 55. CONCLUSIONS: These data show that the outcome of living donor transplants has continued to improve. However, for living donors, donor source affects outcome. The authors also identify other major risk factors affecting both short- and long-term outcome.     

Changes in portal vein flow after adult living-donor liver transplantation: Does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)     

Intra-operative management of low portal vein flow in pediatric living donor liver transplantation

For pediatric living donor liver transplantation, portal vein complications cause significant morbidity and graft failure. Routine intra-operative Doppler ultrasound is performed after graft reperfusion to evaluate the flow of portal vein. This retrospective study reviewed 65 children who had undergone living donor liver transplantation. Seven patients were detected with suboptimal portal vein flow velocity following vascular reconstruction and abdominal closure. They underwent immediate on-table interventions to improve the portal vein flow. Both surgical and endovascular modalities were employed, namely, graft re-positioning, collateral shunt ligation, thrombectomy, revision of anastomosis, inferior mesenteric vein cannulation, and endovascular stenting. The ultrasonographic follow-up assessment for all seven patients demonstrated patent portal vein and satisfactory flow. We reviewed our experience on the different modalities and proposed an approach for our future intra-operative management to improve portal vein flow at the time of liver transplantation.     

Outflow reconstruction in recipients of right liver graft from living donors

Right-lobe transplantation is now a commonly used procedure in living donor liver transplantation (LDLT) to adult recipients. However, the risk for outflow obstruction is still an issue in LDLT. The right hepatic vein (RHV) was anastomosed end to end to the graft hepatic vein without unfavorable tension on the anastomosis. The anterior wall of the recipient hepatic vein was incised longitudinally, and a V-shaped vein graft was patched to form a wide and long orifice. This new hepatic venoplasty was used in 14 adult patients who received right liver grafts and gave good results without stenosis of the hepatic venous anastomosis or other complications. Our new technique may be useful in recipients of a right liver graft when the recipient or graft RHV is not long enough. (Liver Transpl 2002;8:167-168.)     

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??Adult-adult right lobe graft living donor liver transplantation: an analysis of 21 cases LIN Dong-dong, LU Shi-chun, LI Ning, et al. Liver Transplantation Center, Beijing You’an Hospital, Capital Medical University, Beijing 100069, China
Corresponding author??LI Ning, E-mail??liningbjyah@vip.sina.com
Abstract Objective To investigate the key technical skills in adult-adult right lobe graft living donor liver transplantation. Methods The clinical data of 21 adult donors and recipients who underwent right lobe living donor liver transplantation from April 2007 to May 2009 at Beijing You’an Hospital Affiliated to Capital Medical University were analyzed retrospectively. Results There was no death in donors. Twenty-three complications were cured smoothly. Fifteen complications belonged to Grade I and the other 8 complications belonged to Grade II by Clavien classification. There were 4 recipients death in one month after operation and 7 biliary complications occurred during following-up period. All biliary complications were cured by surgical procedures. Four right lobe grafts included middle hepatic vein (group A), 17 right lobe grafts didn’t include middle hepatic vein (group B). There was no significant difference (χ2 =1.000, P=0.617) in 1 year survival rate between group A (75%) and group B (76%). Conclusion Adult-adult right lobe living donor liver transplantation is an important modality for end-stage liver disease patients, especially for patients with liver failure. Rigorous preoperative evaluation, careful operation, proper distribution of middle hepatic vein to maintain graft and remnant liver functional volume, and intensive postoperative care are guarantee for the safety of donors and recipients in living donor liver transplantation.     

Review of the surgical approach to prevent small-for-size syndrome in recipients after left lobe adult LDLT

Left lobe liver grafts increase the donor safety in adult-to-adult living-donor liver transplantation (ALDLT). However, the left lobe graft provides about 30–50 % of the required liver volume to adult recipients, which is insufficient to sustain their metabolic demands, which can lead to small-for-size syndrome (SFSS). Transient portal hypertension and microcirculatory hemodynamic derangement, apart from outflow obstruction, during the first week after reperfusion are the critical events associated with small-for-size graft transplantation. The incidence of SFSS in left lobe ALDLT can be decreased by increasing the left lobe graft volume by effective utilization of the caudate lobe with preserved vascular supply, by modulating the portal pressure with splenectomy or a porto-systemic shunt or by hepatic venous outflow reconstruction to prevent the development of venous congestion. In this review, we discuss the pathophysiology of SFSS and the various surgical strategies that can be performed to prevent SFSS in an effort to enhance the donor safety during living-donor liver transplantation.     

Hepatic vein reconstruction in living donor liver transplantation

INTRODUCTION: Living donor liver transplantation has emerged as a response to the cadaveric graft shortage, especially for adult recipients. Both right and left liver grafts are widely used, although some technical problems remain unresolved. Herein we describe our technique for reconstruction of the venous outflow in living donor liver transplantation. METHODS: From April 1986 to September 2004, 1012 liver transplantations were performed including 30 living donor liver transplantations between April 1995 and September 2004. We have selected the first 28 cases to ensure a mean follow-up of 21.07 +/- 13.11 months. We transplanted 18 right lobe grafts, 7 left lobe grafts, and 3 left lateral segment grafts. A surgical technique is described herein. RESULTS: No venous outflow obstruction developed among living donor liver transplantation recipients. CONCLUSION: We recommend reconstruction of the hepatic veins in living donor liver transplantation including joining together the three hepatic veins in the recipient to avoid venous outflow obstruction.     

活体肝移植的几点关键外科技术

目的：探讨活体肝移植的几点关键外科技术。方法：2001年1月至2002年3月底,实施活体肝移植11例,其中左半肝8例,左外叶1例,成人右半肝2例;根据术前CT、血管造影和术中B超确定肝切除线,超声电刀离断肝实质,经门静脉灌注原位获取。受体手术采用保留腔静脉的全肝切除。移植肝原位植入,肝静脉重建采用扩大成型吻合技术,显微技术吻合肝动脉,胆道重建采用端端吻合,置“T“管引流。结果：11例供体术后顺利康复出院,未发生严重并发症。11例受体中,1例发生肝动脉血栓形成需再次肝移植,1例因不可逆转的严重排斥反应,于术后72d死亡。10例受体康复出院,肝功能、铜氧化酶恢复正常。结论：活体肝移植对供体是相对安全的。管道重建技术是活体肝移植的重要环节。术前、术中了解供体的解剖变异并正确处理,可降低并发症发生率。     

Living related liver transplantation in children: a report of the first 58 recipients at the University of Chicago

Abstract From November 1989 58 living donor liver transplants were performed in 56 children ranging in age from 1 month to 13 years. Donors were adults (> 18 years of age) with a close relationship to the recipient. ABO compatibility and normal donor health were required. Liver segments two and three were transplanted in 53 cases, and segments two, three and four in 5 cases. Actuarial patient survival at 2 years was 89%; graft survival was 76%. Six recipients died: four secondary to sepsis and two because of post-transplant lymphoproliferative disease. The main cause of graft loss was arterial thrombosis, occurring in six patients (10%). Since refinement of the technique, there have been few donor complications, but these have included a biliary tract injury and a hepatic artery thrombosis. Both donors are well, without long-term adverse sequelae. Overall, the outcome of living donor transplantation is excellent; morbidity has been encountered in a small number of donors.